Pregnancy Intention: Associations with Maternal Behaviors and Experiences During and After Pregnancy.

Background: The associations between levels of pregnancy intention and adverse behaviors or experiences during pregnancy and postpartum have not been well described. Materials and Methods: We used 2018 Pregnancy Risk Assessment Monitoring System data from 31 jurisdictions in the United States (n = 32,777) to estimate prevalence of inadequate prenatal care (PNC), inappropriate gestational weight gain, depression during pregnancy, intimate partner violence (IPV) during pregnancy, third trimester smoking, no breastfeeding, no postpartum visit, postpartum depressive symptoms, and postpartum smoking by categories of pregnancy intention: unwanted, ambivalent (i.e., unsure), mistimed (i.e., wanted later), or wanted (i.e., wanted then/sooner). Regression models estimated adjusted prevalence ratios (aPR) and 95% confidence intervals (CIs) of associations between pregnancy intention and maternal behaviors or experiences. Results: Approximately 16% of women reported pregnancy ambivalence. Women with pregnancy ambivalence (versus wanted pregnancies) had higher prevalence of all adverse maternal behaviors and experiences. Separate models found women with unwanted pregnancy (vs. ambivalent) had higher prevalence for depression during pregnancy (aPR: 1.40, 95% CI: 1.21-1.63), IPV (aPR: 1.75, 95% CI: 1.11-2.77), no breastfeeding (aPR: 1.22, 95% CI: 1.04-1.44), no postpartum visit (aPR: 1.28, 95% CI: 1.06-1.55), and postpartum depressive symptoms (aPR: 1.19, 95% CI: 1.00-1.42); Women with mistimed pregnancy (vs. ambivalent) had lower prevalence for inadequate PNC (aPR: 0.89, 95% CI: 0.81-0.98), third trimester smoking (aPR: 0.68, 95% CI: 0.57-0.80), no breastfeeding (aPR: 0.85, 95% CI: 0.74-0.98), and postpartum smoking (aPR: 0.83, 95% CI: 0.73-0.95). Discussion: The results emphasize the importance of recommended screening and care during the preconception, prenatal, and postpartum periods.

Trends in Selected Chronic Conditions and Related Risk Factors Among Women of Reproductive Age: Behavioral Risk Factor Surveillance System, 2011-2017.

Introduction: Chronic diseases in the United States are the leading drivers of disability, death, and health care costs. In women of reproductive age (WRA), chronic disease and related risk factors can also affect fertility and reproductive health outcomes. This analysis of trends from 2011 to 2017 adds additional indicators and updates an analysis covering 2001-2009. Methods: Data from the 2011-2017 Behavioral Risk Factor Surveillance System were analyzed for 265,544 WRA (18-44 years). To assess trends in 12 chronic conditions and related risk factors, we calculated annual prevalence estimates and adjusted prevalence ratios (APRs) with predicted marginals accounting for age, race, Hispanic ethnicity, education, and health care coverage. Results: From 2011 to 2017, prevalence decreased for current smoking (20.7%-15.9%; p < 0.001), gestational diabetes (3.1%-2.7%; p = 0.003), and high cholesterol (19.0%-16.7%; p < 0.001); prevalence increased for depression (20.4%-24.9%; p < 0.001) and obesity (24.6%-27.6%; p < 0.001). After adjustment, in 2017 WRA were more likely to report asthma (APR = 1.06; 95% confidence interval [CI] = 1.01-1.11), physical inactivity (APR = 1.08; 95% CI = 1.04-1.12), obesity (APR = 1.15; 95% CI = 1.11-1.19), and depression (APR = 1.29; 95% CI = 1.25-1.34) compared with 2011. They were less likely to report high cholesterol (APR = 0.89; 95% CI = 0.85-0.94) in 2015 compared with 2011, and current smoking (APR = 0.86; 95% CI = 0.82-0.89) and gestational diabetes (APR = 0.84; 95% CI = 0.75-0.94) in 2017 compared with 2011. Conclusions: Some chronic conditions and related risk factors improved, whereas others worsened over time. Research clarifying reasons for these trends may support the development of targeted interventions to promote improvements, potentially preventing adverse reproductive outcomes and promoting long-term health.

Preconception Health Indicators for Public Health Surveillance.

OBJECTIVES: In response to an expressed need for more focused measurement of preconception health (PCH), we identify a condensed set of PCH indicators for state and national surveillance. METHODS: We used a systematic process to evaluate, prioritize, and select 10 PCH indicators that maternal and child health programs can use for surveillance. For each indicator, we assessed prevalence, whether it was addressed by professional recommendations, Healthy People 2020 objectives, or Centers for Disease Control and Prevention winnable battles, measurement simplicity, data completeness, and stakeholders' input. RESULTS: Fifty PCH indicators were evaluated and prioritized. The condensed set includes indicators that rely on data from the Pregnancy Risk Assessment Monitoring System (n = 4) and the Behavioral Risk Factor Surveillance System (n = 6). The content encompasses heavy alcohol consumption, depression, diabetes, folic acid intake, hypertension, normal weight, recommended physical activity, current smoking, unwanted pregnancy, and use of contraception. CONCLUSIONS: Having a condensed set of PCH indicators can facilitate surveillance of reproductive-aged women's health status that supports monitoring, comparisons, and benchmarking at the state and national levels.

Disparities in Preconception Health Indicators - Behavioral Risk Factor Surveillance System, 2013-2015, and Pregnancy Risk Assessment Monitoring System, 2013-2014.

PROBLEM/CONDITION: Preconception health is a broad term that encompasses the overall health of nonpregnant women during their reproductive years (defined here as aged 18-44 years). Improvement of both birth outcomes and the woman's health occurs when preconception health is optimized. Improving preconception health before and between pregnancies is critical for reducing maternal and infant mortality and pregnancy-related complications. The National Preconception Health and Health Care Initiative's Surveillance and Research work group suggests ten prioritized indicators that states can use to monitor programs or activities for improving the preconception health status of women of reproductive age. This report includes overall and stratified estimates for nine of these preconception health indicators. REPORTING PERIOD: 2013-2015. DESCRIPTION OF SYSTEMS: Survey data from two surveillance systems are included in this report. The Behavioral Risk Factor Surveillance System (BRFSS) is an ongoing state-based, landline and cellular telephone survey of noninstitutionalized adults in the United States aged ≥18 years that is conducted by state and territorial health departments. BRFSS is the main source of self-reported data for states on health risk behaviors, chronic health conditions, and preventive health services primarily related to chronic disease in the United States. The Pregnancy Risk Assessment Monitoring System (PRAMS) is an ongoing U.S. state- and population-based surveillance system administered collaboratively by CDC and state health departments. PRAMS is designed to monitor selected maternal behaviors, conditions, and experiences that occur before, during, and shortly after pregnancy that are self-reported by women who recently delivered a live-born infant. This report summarizes BRFSS and PRAMS data on nine of 10 prioritized preconception health indicators (i.e., depression, diabetes, hypertension, current cigarette smoking, normal weight, recommended physical activity, recent unwanted pregnancy, prepregnancy multivitamin use, and postpartum use of a most or moderately effective contraceptive method) for which the most recent data are available. BRFSS data from all 50 states and the District of Columbia were used for six preconception health indicators: depression, diabetes (excluded if occurring only during pregnancy or if limited to borderline/prediabetes conditions), hypertension (excluded if occurring only during pregnancy or if limited to borderline/prehypertension conditions), current cigarette smoking, normal weight, and recommended physical activity. PRAMS data from 30 states, the District of Columbia, and New York City were used for three preconception health indicators: recent unwanted pregnancy, prepregnancy multivitamin use, and postpartum use of a most or moderately effective contraceptive method by women or their husbands or partners (i.e., male or female sterilization, hormonal implant, intrauterine device, injectable contraceptive, oral contraceptive, hormonal patch, or vaginal ring). Heavy alcohol use during the 3 months before pregnancy also was included in the prioritized set of 10 indicators, but PRAMS data for each reporting area are not available until 2016 for that indicator. Therefore, estimates for heavy alcohol use are not included in this report. All BRFSS preconception health estimates are based on 2014-2015 data except two (hypertension and recommended physical activity are based on 2013 and 2015 data). All PRAMS preconception health estimates rely on 2013-2014 data. Prevalence estimates of indicators are reported for women aged 18-44 years overall, by age group, race-ethnicity, health insurance status, and reporting area. Chi-square tests were conducted to assess differences in indicators by age group, race/ethnicity, and insurance status. RESULTS: During 2013-2015, prevalence estimates of indicators representing risk factors were generally highest and prevalence estimates of health-promoting indicators were generally lowest among older women (35-44 years), non-Hispanic black women, uninsured women, and those residing in southern states. For example, prevalence of ever having been told by a health care provider that they had a depressive disorder was highest among women aged 35-44 years (23.1%) and lowest among women aged 18-24 years (19.2%). Prevalence of postpartum use of a most or moderately effective method of contraception was lowest among women aged 35-44 years (50.6%) and highest among younger women aged 18-24 years (64.9%). Self-reported prepregnancy multivitamin use and getting recommended levels of physical activity were lowest among non-Hispanic black women (21.6% and 42.8%, respectively) and highest among non-Hispanic white women (37.8% and 53.8%, respectively). Recent unwanted pregnancy was lowest among non-Hispanic white women and highest among non-Hispanic black women (5.0% and 11.6%, respectively). All but three indicators (diabetes, hypertension, and use of a most or moderately effective contraceptive method) varied by insurance status; for instance, prevalence of current cigarette smoking was higher among uninsured women (21.0%) compared with insured women (16.1%), and prevalence of normal weight was lower among women who were uninsured (38.6%), compared with women who were insured (46.1%). By reporting area, the range of women reporting ever having been told by a health care provider that they had diabetes was 5.0% (Alabama) to 1.9% (Utah), and women reporting ever having been told by a health care provider that they had hypertension ranged from 19.2% (Mississippi) to 7.0% (Minnesota). INTERPRETATION: Preconception health risk factors and health-promoting indicators varied by age group, race/ethnicity, insurance status, and reporting area. These disparities highlight subpopulations that might benefit most from interventions that improve preconception health. PUBLIC HEALTH ACTION: Eliminating disparities in preconception health can potentially reduce disparities in two of the leading causes of death in early and middle adulthood (i.e., heart disease and diabetes). Public health officials can use this information to provide a baseline against which to evaluate state efforts to improve preconception health.

Receipt of Selected Preventive Health Services for Women and Men of Reproductive Age - United States, 2011-2013.

PROBLEM/CONDITION: Receipt of key preventive health services among women and men of reproductive age (i.e., 15-44 years) can help them achieve their desired number and spacing of healthy children and improve their overall health. The 2014 publication Providing Quality Family Planning Services: Recommendations of CDC and the U.S. Office of Population Affairs (QFP) establishes standards for providing a core set of preventive services to promote these goals. These services include contraceptive care for persons seeking to prevent or delay pregnancy, pregnancy testing and counseling, basic infertility services for those seeking to achieve pregnancy, sexually transmitted disease (STD) services, and other preconception care and related preventive health services. QFP describes how to provide these services and recommends using family planning and other primary care visits to screen for and offer the full range of these services. This report presents baseline estimates of the use of these preventive services before the publication of QFP that can be used to monitor progress toward improving the quality of preventive care received by women and men of reproductive age. PERIOD COVERED: 2011-2013. DESCRIPTION OF THE SYSTEM: Three surveillance systems were used to document receipt of preventive health services among women and men of reproductive age as recommended in QFP. The National Survey of Family Growth (NSFG) collects data on factors that influence reproductive health in the United States since 1973, with a focus on fertility, sexual activity, contraceptive use, reproductive health care, family formation, child care, and related topics. NSFG uses a stratified, multistage probability sample to produce nationally representative estimates for the U.S. household population of women and men aged 15-44 years. This report uses data from the 2011-2013 NSFG. The Pregnancy Risk Assessment Monitoring System (PRAMS) is an ongoing, state- and population-based surveillance system designed to monitor selected maternal behaviors and experiences that occur before, during, and shortly after pregnancy among women who deliver live-born infants in the United States. Annual PRAMS data sets are created and used to produce statewide estimates of preconception and perinatal health behaviors and experiences. This report uses PRAMS data for 2011-2012 from 11 states (Hawaii, Maine, Maryland, Michigan, Minnesota, Nebraska, New Jersey, Tennessee, Utah, Vermont, and West Virginia). The National Health Interview Survey (NHIS) is a nationally representative survey of noninstitutionalized civilians in the United States. NHIS collects data on a broad range of health topics, including the prevalence, distribution, and effects of illness and disability and the services rendered for or because of such conditions. Households are identified through a multistage probability household sampling design, and estimates are produced using weights that account for the sampling design, nonresponse, and poststratification adjustments. This report uses data from the 2013 NHIS for women aged 18-44 years. RESULTS: Many preventive health services recommended in QFP were not received by all women and men of reproductive age. For contraceptive services, including contraceptive counseling and advice, 46.5% of women aged 15-44 years at risk for unintended pregnancy received services in the past year, and 4.5% of men who had vaginal intercourse in the past year received services in that year. For sexually transmitted disease (STD) services, among all women aged 15-24 years who had oral, anal, or vaginal sex with an opposite sex partner in the past year, 37.5% were tested for chlamydia in that year. Among persons aged 15-44 years who were at risk because they were not in a mutually monogamous relationship during the past year, 45.3% of women were tested for chlamydia and 32.5% of men were tested for any STD in that year. For preconception care and related preventive health services, data from selected states indicated that 33.2% of women with a recent live birth (i.e., 2-9 months postpartum) talked with a health care professional about improving their health before their most recent pregnancy; of selected preconception counseling topics, the most frequently discussed was taking vitamins with folic acid before pregnancy (81.2%), followed by achieving a healthy weight before pregnancy (62.9%) and how drinking alcohol (60.3%) or smoking (58.2%) during pregnancy can affect a baby. Nationally, among women aged 18-44 years irrespective of pregnancy status, 80.9% had their blood pressure checked by a health care professional and 31.7% received an influenza vaccine in the past year; 54.5% of those with high blood pressure were tested for diabetes, 44.9% of those with obesity had a health care professional talk with them about their diet, and 55.2% of those who were current smokers had a health professional talk with them about their smoking in the past year. Among all women aged 21-44 years, 81.6% received a Papanicolaou (Pap) test in the past 3 years. Receipt of certain preventive services varied by age and race/ethnicity. Among women with a recent live birth, the percentage of those who talked with a health care professional about improving their health before their most recent pregnancy increased with age (range: 25.9% and 25.2% for women aged ≤19 and 20-24 years, respectively, to 35.9% and 37.8% for women aged 25-34 and ≥35 years, respectively). Among women with a recent live birth, the percentage of those who talked with a health care professional about improving their health before their most recent pregnancy was higher for non-Hispanic white (white) (35.2%) compared with non-Hispanic black (black) (30.0%) and Hispanic (26.0%) women. Conversely, across most STD screening services evaluated, testing was highest among black women and men and lowest among their white counterparts. Receipt of many preventive services recommended in QFP increased consistently across categories of family income and continuity of health insurance coverage. Prevalence of service receipt was highest among women in the highest family income category (>400% of federal poverty level [FPL]) and among women with insurance coverage for each of the following: contraceptive services among women at risk for unintended pregnancy; medical services beyond advice to help achieve pregnancy; vaccinations (hepatitis B and human papillomavirus [HPV], ever; tetanus, past 10 years; influenza, past year); discussions with a health care professional about improving health before pregnancy and taking vitamins with folic acid; blood pressure and diabetes screening; discussions with a health care professional in the past year about diet, among those with obesity; discussions with a health care professional in the past year about smoking, among current smokers; Pap tests within the past 3 years; and mammograms within the past 2 years. INTERPRETATION: Before 2014, many women and men of reproductive age were not receiving several of the preventive services recommended for them in QFP. Although differences existed by age and race/ethnicity, across the range of recommended services, receipt was consistently lower among women and men with lower family income and greater instability in health insurance coverage. PUBLIC HEALTH ACTION: Information in this report on baseline receipt during 2011-2013 of preventive services for women and men of reproductive age can be used to target improvements in the use of recommended services through the development ofresearch priorities, information for decision makers, and public health practice. Health care administrators and practitioners can use the information to identify subpopulations with the greatest need for preventive services and make informed decisions on resource allocation. Public health researchers can use the information to guide research on the determinants of service use and factors that might increase use of preventive services. Policymakers can use this information to evaluate the impact of policy changes and assess resource needs for effective programs, research, and surveillance on the use of preventive health services for women and men of reproductive age.

Associations between noncommunicable disease risk factors, race, education, and health insurance status among women of reproductive age in Brazil - 2011.

BACKGROUND: Noncommunicable disease (NCD) risk factors increase the risk of adverse reproductive health outcomes and are becoming increasingly common in Brazil. METHODS: We analyzed VIGITEL 2011 telephone survey data for 13,745 Brazilian women aged 18-44 years in a probabilistic sample from 26 Brazilian state capitals and the Federal District. We examined associations between NCD risk factors (fruit and vegetable intake, leisure time physical activity, alcohol consumption, smoking status, BMI and hypertension status) and race, education, and insurance using chi-square tests and multivariable logistic regression models, estimating the average marginal effects to produce adjusted relative risk ratios (aRRs). Analyses were conducted using SAS 9.3 survey procedures and weighted to reflect population estimates. RESULTS: Women with less than a college education were more likely to report physical inactivity (adjusted relative risk (aRR) and 95% confidence interval = 1.1 (1.1-1.2)), smoking (aRR = 1.7 (1.3-2.2)), and self-reported diagnoses of hypertension (aRR = 2.0 (1.6-2.5)) compared to women with a college education or greater. Similarly, women without health insurance were more likely to report physical inactivity (aRR = 1.1 (1.1-1.2)), smoking (aRR = 1.4 (1.1-1.8)), and self-reported diagnoses of hypertension aRR = 1.4 (1.1-1.7)) compared to women with health insurance. Less variation was found by race and NCD risk factors. CONCLUSION: Targeted public health strategies and policies are needed to increase healthcare access and decrease educational and racial disparities in NCD risk factors among women of reproductive age in Brazil.

Postpartum Smoking Relapse After Quitting During Pregnancy: Pregnancy Risk Assessment Monitoring System, 2000-2011.

BACKGROUND: Relapsing to smoking postpartum jeopardizes a woman's health and her infant's health. Our study estimated the proportion and identified characteristics associated with postpartum relapse using a large population-based sample. MATERIALS AND METHODS: We analyzed Pregnancy Risk Assessment Monitoring System data among women with live births. Relapse was defined as smoking at survey completion among those who quit by the last 3 months of pregnancy. We assessed linear trends for relapse during 2000-2011 in 40 sites overall and individually using logistic regression. Adjusted prevalence ratios (aPRs) were calculated to assess characteristics associated with relapse during 2009-2011 (n = 13,076). RESULTS: During 2000-2011, the proportion of women who relapsed postpartum remained unchanged overall (p = 0.84) and by site (p ≥ 0.05 for each), ranging in 2011 from 30.8% to 52.2% (Wyoming-Arkansas). Characteristics associated with relapse compared with reference groups were prepregnancy daily smoking (aPR = 1.80; 95% confidence interval (CI): 1.59-2.04); age <20 years (aPR = 1.51; 1.24-1.84), 20-24 years (aPR = 1.39; 1.17-1.65), or 25-34 years (aPR = 1.26; 1.07-1.48); not initiating breastfeeding (aPR = 1.34; 1.24-1.44); not having a complete home smoking ban (aPR = 1.27; 1.14-1.42); being black non-Hispanic (aPR = 1.25; 1.14-1.38); being multiparous (aPR = 1.20; 1.11-1.28); experiencing 3-5 stressors during pregnancy (aPR = 1.12; 1.01-1.24); having an unintended pregnancy (aPR = 1.11; 1.03-1.19); and having 12 years of education (aPR = 1.09; 1.01-1.17). CONCLUSIONS: There was no change in the proportion of women relapsing postpartum during 2000-2011. In 2011, nearly half (42%) of women relapsed after quitting smoking during pregnancy. Disparities exist by site and by maternal characteristics. A comprehensive approach maximizing tobacco control efforts and developing effective clinical interventions delivered across sectors is necessary for long-term tobacco abstinence among women.

Outcomes of cardiovascular disease risk factor screening and referrals in a family planning clinic.

BACKGROUND: Cardiovascular disease (CVD) screening in Title X settings can identify low-income women at risk of future chronic disease. This study examines follow-up related to newly identified CVD risk factors in a Title X setting. METHODS: Female patients at a North Carolina Title X clinic were screened for CVD risk factors (n=462) and 167/462 (36.1%) were rescreened one year later. Clinical staff made protocol-driven referrals for women identified with newly diagnosed CVD risk factors. We used paired t-tests and chi square tests to compare screening and rescreening results (two-tailed, p<0.05). RESULTS: Among 11 women in need of referrals for newly diagnosed hypertension or diabetes, 9 out of 11 (81.8%) were referred, and 2 of 11 (18.2%) completed referrals. Among hypertensive women who were rescreened (n=21), systolic blood pressure decreased (139 to 132 mmHg, p=0.001) and diastolic blood pressure decreased (90 to 83 mmHg, p=0.006). Hemoglobin A1c did not improve among rescreened diabetic women (n=5, p=0.640). Among women who reported smoking at enrollment, 129 of 148 (87.2%) received cessation counseling and 8 of 148 (5.4%) accepted tobacco quitline referrals. Among smokers, 53 out of 148 (35.8%) were rescreened and 11 of 53 (20.8%) reported nonsmoking at that time. Among 188 women identified as obese at enrollment, 22 (11.7%) scheduled nutrition appointments, but only one attended. Mean weight increased from 221 to 225 pounds (p 0<.05) among 70 out of 188 (37.2%) obese women who were rescreened. CONCLUSIONS: The majority of women in need of referrals for CVD risk factors received them. Few women completed referrals. Future research should examine barriers and facilitators of referral care among low-income women.

Core state preconception health indicators - pregnancy risk assessment monitoring system and behavioral risk factor surveillance system, 2009.

PROBLEM/CONDITION: Promoting preconception health can potentially improve women's health and pregnancy outcomes. Evidence-based interventions exist to reduce many maternal behaviors and chronic conditions that are associated with adverse pregnancy outcomes such as tobacco use, alcohol use, inadequate folic acid intake, obesity, hypertension, and diabetes. The 2006 national recommendations to improve preconception health included monitoring improvements in preconception health by maximizing public health surveillance (CDC. Recommendations to improve preconception health and health care-United States: a report of the CDC/ATSDR Preconception Care Work Group and the Select Panel on Preconception Care. MMWR 2006;55[No. RR-6]). REPORTING PERIOD COVERED: 2009 for 38 indicators; 2008 for one indicator. DESCRIPTION OF SURVEILLANCE SYSTEMS: The Pregnancy Risk Assessment Monitoring System (PRAMS) is an ongoing state- and population-based surveillance system designed to monitor selected self-reported maternal behaviors, conditions, and experiences that occur shortly before, during, and after pregnancy among women who deliver live-born infants. The Behavioral Risk Factor Surveillance System (BRFSS) is an ongoing state-based telephone survey of noninstitutionalized adults aged ≥18 years in the United States that collects state-level data on health-related risk behaviors, chronic conditions, and preventive health services. This surveillance summary includes PRAMS data from 29 reporting areas (n = 40,388 respondents) and BRFSS data from 51 reporting areas (n = 62,875 respondents) for nonpregnant women of reproductive age (aged 18-44 years). To establish a comprehensive, nationally recognized set of indicators to be used for monitoring, evaluation, and response, a volunteer group of policy and program leaders and epidemiologists identified 45 core state preconception health indicators, of which 41 rely on PRAMS or BRFSS as data sources. This report includes 39 of the 41 core state preconception health indicators for which data are available through PRAMS or BRFSS. The two indicators from these data sources that are not described in this report are human immunodeficiency virus (HIV) testing within a year before the most recent pregnancy and heavy drinking on at least one occasion during the preceding month. Ten preconception health domains are examined: general health status and life satisfaction, social determinants of health, health care, reproductive health and family planning, tobacco and alcohol use, nutrition and physical activity, mental health, emotional and social support, chronic conditions, and infections. Weighted prevalence estimates and 95% confidence intervals (95% CIs)for 39 indicators are presented overall and for each reporting area and stratified by age group (18-24, 25-34, and 35-44 years) and women's race/ethnicity (non-Hispanic white, non-Hispanic black, non-Hispanic other, and Hispanic). RESULTS: This surveillance summary includes data for 39 of 41 indicators: 2009 data for 23 preconception health indicators that were monitored by PRAMS and 16 preconception health indicators that were monitored by BRFSS (one BRFSS indicator uses 2008 data). For two of the indicators that are included in this report (prepregnancy overweight or obesity and current overweight or obesity), separate measures of overweight and obesity were reported. All preconception health indicators varied by reporting area, and most indicators varied significantly by age group and race/ethnicity. Overall, 88.9% of women of reproductive age reported good, very good, or excellent general health status and life satisfaction (BRFSS). A high school/general equivalency diploma or higher education (social determinants of health domain) was reported by 94.7% of non-Hispanic white, 92.9% of non-Hispanic other, 91.1% of non-Hispanic black, and 70.9% of Hispanic women (BRFSS). Overall, health-care insurance coverage during the month before the most recent pregnancy (health-care domain) was 74.9% (PRAMS). A routine checkup during the preceding year was reported by 79.0% of non-Hispanic black, 65.1% of non-Hispanic white, 64.3% of other, and 63.0% of Hispanic women (BRFSS). Among women with a recent live birth (2-9 months since date of delivery), selected PRAMS results for the reproductive health and family planning, tobacco and alcohol use, and nutrition domains included several factors. Although 43% of women reported that their most recent pregnancy was unintended (unwanted or wanted to be pregnant later), approximately half (53%) of those who were not trying to get pregnant reported not using contraception at the time of conception. Smoking during the 3 months before pregnancy was reported by 25.1% of women, and drinking alcohol 3 months before pregnancy was reported by 54.2% of women. Daily use of a multivitamin, prenatal vitamin, or a folic acid supplement during the month before pregnancy was reported by 29.7% of women. Selected BRFSS results included indicators pertaining to the nutrition and physical activity, emotional and social support, and chronic conditions domains among women of reproductive age. Approximately one fourth (24.7%) of women were identified as being obese according to body mass index (BMI) on the basis of self-reported height and weight. Overall, 51.6% of women reported participation in recommended levels of physical activity per U.S. Department of Health and Human Services physical activity guidelines. Non-Hispanic whites reported the highest prevalence (85.0%) of having adequate emotional and social support, followed by other races/ethnicities (74.9%), Hispanics (70.5%), and non-Hispanic blacks (69.7%). Approximately 3.0% of persons reported ever being diagnosed with diabetes, and 10.2% of women reported ever being diagnosed with hypertension. INTERPRETATION: The findings in this report underscore opportunities for improving the preconception health of U.S. women. Preconception health and women's health can be improved by reducing unintended pregnancies, reducing risky behaviors (e.g., smoking and drinking) among women of reproductive age, and ensuring that chronic conditions are under control. Evidence-based interventions and clinical practice guidelines exist to address these risks and to improve pregnancy outcomes and women's health in general. The results also highlight the need to increase access to health care for all nonpregnant women of reproductive age and the need to encourage the use of essential preventive services for women, including preconception health services. In addition, system changes in community settings can alleviate health problems resulting from inadequate social and emotional support and environments that foster unhealthy lifestyles. Policy changes can promote health equity by encouraging environments that promote healthier options in nutrition and physical activity. Finally, variation in the preconception health status of women by age and race/ethnicity underscores the need for implementing and scaling up proven strategies to reduce persistent health disparities among those at highest risk. Ongoing surveillance and research in preconception health are needed to monitor the influence of improved health-care access and coverage on women's prepregnancy and interpregnancy health status, pregnancy and infant outcomes, and health disparities. PUBLIC HEALTH ACTION: Public health decision makers, program planners, researchers, and other key stakeholders can use the state-level PRAMS and BRFSS preconception health indicators to benchmark and monitor preconception health among women of reproductive age. These data also can be used to evaluate the effectiveness of preconception health state and national programs and to assess the need for new programs, program enhancements, and policies.

Strategies associated with higher postpartum glucose tolerance screening rates for gestational diabetes mellitus patients.

BACKGROUND: Most women with histories of gestational diabetes mellitus do not receive a postpartum screening test for type 2 diabetes, even though they are at increased risk. The objective of this study was to identify factors associated with high rates of postpartum glucose screening. METHODS: This cross-sectional analysis assessed characteristics associated with postpartum diabetes screening for patients with gestational diabetes mellitus (GDM)-affected pregnancies self-reported by randomly sampled licensed obstetricians/gynecologists (OBs/GYNs) in Ohio in 2010. RESULTS: Responses were received from 306 OBs/GYNs (56.5% response rate), among whom 69.9% reported frequently (always/most of the time) screening women with GDM-affected pregnancies for abnormal glucose tolerance at the postpartum visit. Compared to infrequent screeners, OBs/GYNs who frequently screen for postpartum glucose tolerance were statistically (p<0.05) more likely to have a clinical protocol addressing postpartum testing (67.2% vs. 26.7%), an electronic reminder system for providers (10.8% vs. 2.2%) and provide reminders to patients (16.4% vs. 4.4%). Frequent screeners were more likely to use recommended fasting blood glucose or 2-hour oral glucose tolerance test (61.8% vs. 34.6%, p<0.001) than infrequent screeners. CONCLUSIONS: Strategies associated with higher postpartum glucose screening for GDM patients included clinical protocols for postpartum testing, electronic medical records to alert providers of the need for testing, and reminders to patients.

Cholesterol screening for women: who is "at-risk"?

BACKGROUND: High cholesterol often precedes cardiovascular disease (CVD) and guidelines recommend cholesterol screening among at-risk women. Definitions of CVD risk vary and prevalence of dyslipidemia (abnormal total cholesterol, high-density lipoprotein (HDL-C), or non-HDL-C) among at-risk women may vary by age and definition of CVD risk. METHODS: This study used 2007-2008 National Health and Nutrition Examination Survey data (n=1,781), a representative sample of the U.S. civilian, non-institutionalized population, to estimate the proportion of women without previous dyslipidemia diagnosis who are U.S. Preventive Services Task Force (USPSTF) at-risk and American Heart Association (AHA) at-risk. We also report dyslipidemia prevalence stratified by age. RESULTS: Over half (55.0%) of younger women (20-44 years) and 74.2% of older women (≥45 years) were USPSTF at-risk, while nearly all younger and older women had at least one AHA risk factor (99.5% and 99.6%, respectively). Dyslipidemia prevalence among younger women was 47.3% (95% confidence interval [CI]: 42.2-52.5) for USPSTF-at-risk and 39.5% (95% CI: 35.7-43.4) for AHA at-risk. Among older women, it was 65.5% (95% CI: 60.8-69.9) for USPSTF at-risk and 63.3% (95% CI: 59.0-67.4) for AHA at-risk. CONCLUSIONS: The AHA risk definition identified 45% more young women and 25% more older women than the USPSTF risk definition; however, both definitions of at-risk identified similar prevalence estimates of dyslipidemia among women. Given a high prevalence of dyslipidemia among younger women, future research is needed to assess whether identification and treatment of young women with dyslipidemia will decrease CVD mortality among them later in life.

Screening low-income women of reproductive age for cardiovascular disease risk factors.

UNLABELLED: Abstract Background: Identifying and treating chronic diseases, their precursors, and other cardiovascular disease (CVD) risk factors during family planning visits may improve long-term health and reproductive outcomes among low-income women. A cross-sectional study design was used to describe the prevalence of chronic diseases (hypertension, high cholesterol, and diabetes), their precursors (pre-hypertension, borderline high cholesterol, and pre-diabetes), and related CVD risk factors (such as obesity, smoking, and physical inactivity) among low-income women of reproductive age. METHODS: Prevalence of chronic diseases, their precursors, and related CVD risk factors were assessed for 462 out of 859 (53.8%) female family planning patients, ages 18-44 years, who attended a Title X clinic in eastern North Carolina during 2011 and 2012 and consented to participate. Data were obtained from clinical measurements, blood test results, and questionnaire. Differences in distribution of demographic and health care characteristics and CVD risk factors by presence of prehypertension and pre-diabetes were assessed by Pearson chi-square tests. RESULTS: The prevalence of hypertension was 12%, high cholesterol 16%, and diabetes 3%. Nearly two-thirds of women with hypertension were newly diagnosed (62%) as were 75% of women with diabetes. The prevalence of pre-hypertension was 35%, pre-diabetes 31%, obesity 41%, smoking 32%, and physical inactivity 42%. The majority of participants (87%) had one or more chronic disease or related cardiovascular disease risk factor. CONCLUSIONS: CVD screening during family planning visits can identify significant numbers of women at risk for poor pregnancy outcomes and future chronic disease and can provide prevention opportunities if effective interventions are available and acceptable to this population.

Gestational diabetes mellitus and postpartum care practices of nurse-midwives.

INTRODUCTION: Postpartum screening for glucose intolerance among women with recent histories of gestational diabetes mellitus (GDM) is important for identifying women with continued glucose intolerance after birth, yet screening rates are suboptimal. In a thorough review of the literature, we found no studies of screening practices among certified nurse-midwives (CNMs). The objectives of our study were to estimate the prevalence of postpartum screening for abnormal glucose tolerance and related care by CNMs for women with recent histories of GDM and to identify strategies for improvement. METHODS: From October through December 2010, the Ohio Department of Health sent a survey by mail and Internet to all licensed CNMs practicing in Ohio. We calculated prevalence estimates for knowledge, attitudes, clinical practices, and behaviors related to postpartum diabetes screening. Chi-square statistics were used to assess differences in self-reported clinical behaviors by frequency of postpartum screening. RESULTS: Of the 146 CNMs who provided postpartum care and responded to the survey (62.2% response rate), 50.4% reported screening women with GDM-affected pregnancies for abnormal glucose tolerance at the postpartum visit. Of CNMs who screened postpartum, only 48.4% used fasting blood sugar or the 2-hour oral glucose tolerance test. Although 86.2% of all responding CNMs reported that they inform women with recent histories of GDM of their increased risk for type 2 diabetes mellitus, only 63.1% counseled these women to exercise regularly and 23.3% reported referring overweight/obese women to a diet support group or other nutrition counseling. CNMs reported that identification of community resources for lifestyle interventions and additional training in postpartum screening guidelines may help to improve postpartum care. DISCUSSION: CNMs in Ohio reported suboptimal levels of postpartum diabetes testing and use of a recommended postpartum test. Providing CNMs with additional training and identifying community resources to support needed lifestyle behavior change may improve care for women with recent GDM-affected pregnancies.

Blood pressure and cholesterol screening prevalence among U.S. women of reproductive age opportunities to improve screening.

BACKGROUND: Blood pressure and cholesterol screening among women of reproductive age are important for early disease detection and intervention, and because hypertension and dyslipidemia are associated with adverse pregnancy outcomes. PURPOSE: The objective of this study was to examine associations of sociodemographic characteristics, cardiovascular disease risk factors, and healthcare access indicators with blood pressure and cholesterol screening among women of reproductive age. METHODS: In 2011, prevalence estimates for self-reported blood pressure screening within 2 years and cholesterol screening within 5 years and AORs for screenings were calculated for 4837 women aged 20-44 years, using weighted 2008 National Health Interview Survey data. RESULTS: Overall, recommended blood pressure and cholesterol screening was received by 89.6% and 63.3% women, respectively. Those who were underinsured or uninsured had the lowest screening percentage at 76.6% for blood pressure (95% CI=73.4, 79.6) and 47.6% for cholesterol (95% CI=43.8, 51.5) screening. Suboptimal cholesterol screening prevalence was also found for women who smoke (54.5%, 95% CI=50.8, 58.2); obese women (69.8%, 95% CI=66.3, 73.0); and those with cardiovascular disease (70.3%, 95% CI=63.7, 76.1), prediabetes (73.3%, 95% CI= 64.1, 80.8), or hypertension (81.4%, 95% CI=76.6, 85.4). CONCLUSIONS: Most women received blood pressure screening, but many did not receive cholesterol screening. Universal healthcare access may improve screening prevalence.

Gestational hypertension: a neglected cardiovascular disease risk marker.

OBJECTIVE: The purpose of this study is to examine hypertension and cholesterol screening, knowledge of heart attack symptoms, and cardiovascular disease (CVD) risk factors among women with a history of gestational hypertension. STUDY DESIGN: We used weighted 2008 National Health Interview Survey data to examine health indicators and modifiable CVD risk factors and to estimate prevalence and adjusted odds ratios for recommended CVD screening and knowledge of heart attack symptoms by hypertension history among 11,970 adult women. RESULTS: Among women with gestational hypertension only (n = 301), 93% received the recommended screening for hypertension; 75% received screening for dyslipidemia, and 40% correctly identified 5 of 5 heart attack symptoms. The odds of CVD screenings and knowledge did not differ between women with a history of gestational hypertension and those with no hypertension. However, women with gestational hypertension had higher rates of obesity (43%), CVD (18%), and diabetes mellitus (13%), compared with women without a history of hypertension (21%, 8%, and 3%, respectively). CONCLUSION: A history of gestational hypertension is a neglected CVD risk marker.

Outbreak of pneumonia associated with emergent human adenovirus serotype 14--Southeast Alaska, 2008.

BACKGROUND: In September 2008, an outbreak of pneumonia associated with an emerging human adenovirus (human adenovirus serotype 14 [HAdV-14]) occurred on a rural Southeast Alaska island. Nine patients required hospitalization, and 1 patient died. METHODS: To investigate the outbreak, pneumonia case patients were matched to control participants on the basis of age, sex, and community of residence. Participants in the investigation and their household contacts were interviewed, and serum samples and respiratory tract specimens were collected. Risk factors were evaluated by means of conditional logistic regression. RESULTS: Among 32 pneumonia case patients, 21 (65%) had confirmed or probable HAdV-14 infection. None of 32 matched control participants had evidence of HAdV-14 infection (P<.001 for the difference). Factors independently associated with pneumonia included contact with a known HAdV-14-infected case patient (odds ratio [OR], 18.3 [95% confidence interval {CI}, >or=2.0]), current smoking (OR, 6.7 [95% CI, >or=0.9]), and having neither traveled off the island nor attended a large public gathering (OR, 14.7 [95% CI, >or=2.0]). Fourteen (67%) of 21 HAdV-14-positive case patients belonged to a single network of people who socialized and often smoked together and infrequently traveled off the island. HAdV-14 infection occurred in 43% of case-patient household contacts, compared with 5% of control-participant household contacts (P = .005). CONCLUSIONS: During a community outbreak in Alaska, HAdV-14 appeared to have spread mostly among close contacts and not widely in the community. Demographic characteristics and illness patterns among the case patients were similar to those observed in other recent outbreaks of HAdV-14 infection in the United States.

Influence of reproductive factors on mortality after epithelial ovarian cancer diagnosis.

INTRODUCTION: Although many studies have examined the influence of reproductive factors on ovarian cancer risk, few have investigated their effect on ovarian cancer survival. We examined the prognostic influence of reproductive factors on survival after ovarian cancer diagnosis. METHODS: We conducted a longitudinal analysis of 410 women, ages 20 to 54 years, who participated in the 1980 to 1982 Cancer and Steroid Hormone study as incident ovarian cancer cases. We obtained their vital status by linking Cancer and Steroid Hormone records with Surveillance, Epidemiology, and End Results data. We used the Kaplan-Meier approach to estimate survival probabilities and Cox proportional hazards models to estimate hazard ratios (HR) and 95% confidence intervals (95% CI). RESULTS: During a median follow-up of 9.2 years, 212 women died. Of the reproductive factors examined, only age at menarche and number of lifetime ovulatory cycles (LOC) relative to age significantly predicted ovarian cancer survival. Risk for death was higher among women with highest number of LOC compared with those having fewest LOC (HR, 1.67; 95% CI, 1.20-2.33). Women with fewest LOC had the highest 15-year survival (56.7%; 95% CI, 47.8-64.6%), and women with the highest LOC had the poorest (33.3%; 95% CI, 25.3-41.5%). Women whose age at menarche was <12 years had a higher risk of death compared with women whose menses began at > or =14 years (HR, 1.51; 95% CI, 1.02-2.24). CONCLUSIONS: We found that high LOC and early age at menarche were associated with decreased survival after ovarian cancer.